Making the health system work for over 25 million births annually: drivers of the notable decline in maternal and newborn mortality in India

Introduction India’s progress in reducing maternal and neonatal mortality since the 1990s was faster than the regional average. We systematically analysed how national health policies, services for maternal and newborn health, and socioeconomic contextual changes, drove these mortality reductions. Methods The study’s mixed-methods design integrated quantitative trend analyses of mortality, intervention coverage and equity since the 1990s, using the sample registration system and national surveys, with interpretive understandings from policy documents and 13 key informant interviews. Results India’s maternal mortality ratio (MMR) declined from 412 to 103 maternal deaths per 100 000 live births between 1997–1998 and 2017–2019. The neonatal mortality rate (NMR) declined from 46 to 22 per 1000 live births between 1997 and 2019. The average annual rate of mortality reduction increased over time. During this period, coverage of any antenatal care (57%–94%), quality antenatal care (37%–85%) and institutional delivery (34%–90%) increased, as did caesarean section rates among the poorest tertile (2%–9%); these coverage gains occurred primarily in the government (public) sector. The fastest rates for increasing coverage occurred during 2005–2012. The 2005–2012 National Rural Health Mission (which became the National Health Mission in 2012) catalysed bureaucratic innovations, additional resources, pro-poor commitments and accountability. These efforts occurred alongside smaller family sizes and improvements in macroeconomic growth, mobile and road networks, women’s empowerment, and nutrition. These together reduced high-risk births and improved healthcare access, particularly among the poor. Conclusion Rapid reduction in NMR and MMR in India was accompanied by increased coverage of maternal and newborn health interventions. Government programmes strengthened public sector services, thereby expanding the reach of these interventions. Simultaneously, socioeconomic and demographic shifts led to fewer high-risk births. The study’s integrated methodology is relevant for generating comprehensive knowledge to advance universal health coverage.


Table S1. Indicators explored in the multilevel maternal and newborn survival framework
Framework level Indicators Data sources and time periods • Causes of maternal death 2  Special studies related to the SRS, based on verbal autopsy (2001-3 & 2005-6)

Rural population ix 72% 65%
Table S3: Topic guide for in-depth key-informant interviews The first discussion topic invited respondents to reflect on the overall question: ➢ From your professional experience and scientific knowledge, how do you think India was able to reduce maternal and neonatal mortality over the last 20 years?
During this initial discussion, respondents were asked to discuss important policies, strategies, and programs and the underlying factors that enabled these policies, strategies, and programs.We provided a wide range of potential probes to expand the discussion on topics relevant to the respondent's area expertise.For instance, some respondents had more experience on clinical/technical changes (such as treatment protocols and health worker skills) and others on administrative changes (such as management, financing, retention, and recruitment or evaluation); some were maternal health experts, so discussed specific aspects of maternal survival and others focused on neonatology.
The second discussion topic asked respondents to consider differences in high mortality states versus low mortality states.Trigger questions for this topic were: ➢ What did the low mortality states do to maintain ongoing reductions in maternal mortality?In neonatal mortality?➢ What did higher mortality states do to accelerate their reductions in maternal mortality?Sustain their reductions in neonatal mortality?" The third topic focused on the private sector, asking: ➢ What role has the private sector played in improving maternal and neonatal survival in India?What is the private sector doing well?➢ Over the past 20 years, what has shaped the private sector in terms of its role in providing maternal and neonatal healthcare and the quality of care it provides?➢ How has the maternal and neonatal lifesaving capacity of the private sector differed in high versus low mortality clusters?
Fourth, we asked about broader contextual changes, using the discussion question: ➢ In the past 20-30 years, what are some broader contextual movements, trends, events, or forces that have affected maternal and newborn mortality?➢ BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Gender
• Male 8 • Female 5 Current affiliation • Government: administration 2 • Government: technical 2 • Development partner^ 4 • Civil society and academia^ 5 Periods active* • CSSM (1992-1997) 6 • RCH I (1997-2005) 10 • RCH II/NRHM (2005-2012) 12 • RMNCH+A/NHM (2012-present) 11 ^Most development partners and members of civil society and academia had at various points in their careers served as technical advisors to the government through partnerships or involvement in committees.One member of civil society was formerly an employee of the government in a technical role.
* Does not sum to 13 as some respondents were active across multiple policy periods ii Office of the Registrar General and Census Commissioner of India.SRS based abridged life tables 2014-18.Ministry of Home Affairs, Government of India, 2020.
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s)

Table S1 .
Indicators explored in the multilevel maternal and newborn survival framework 2 Causes of maternal and neonatal deaths were not reported in the manuscript because different data sources and analyses resulted in different findings due to data limitations.•Financing (per capita expenditure) BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance

Table S1 .
Indicators explored in the multilevel maternal and newborn survival framework *Analysis not included in the manuscript due to limitations on the quality of data available

Table S2 :
Changes in India over the past two decades on selecteddemographic and socioeconomic  indicators, 2000-20

Table S4 :
Key informant respondent characteristics

Table S5 :
BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) Coverage of any ANC, ANCq (ANC with contents 9+/13), institutional delivery and PNC (among births in the five years preceding the survey) by selected background characteristics, India(NFHS, 2005-6 and 2019-21)BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Supplemental material placed on this supplemental material which has been supplied by the author(s) World Bank.Population total -India[Internet].World Bank Data.2021[cited 2021 Jul 24].Available from: https://data.worldbank.org/indicator/SP.POP.TOTL?locations=IN. i